Natural rubber latex (NRL) is a ubiquitous allergen as it is a component of > 40,000 products in everyday life. Latex allergy might be attributed to skin contact or inhalation of latex particles. Latex allergy is an IgE-mediated hypersensitivity to NRL, presenting a wide range of clinical symptoms such as angioedema, swelling, cough, asthma, and anaphylactic reactions. Until 1979, latex allergy appeared only as type IV delayed hypersensitivity; subsequently, the proportion of different allergy types drifted towards type IV contact allergy reactions. Several risk factors for sensitization to NRL are already known and well documented. Some authors have established a positive correlation between a history of multiple surgical interventions, atopy, spina bifida malformation, and latex allergy incidence. We suspect an increase in latex allergy incidence in association with increased atopy and sensitivity to environmental allergens in the industrial population. It is often postulated in literature that the groups of workers at risk for this allergy are essentially workers in the latex industry and healthcare professionals. In this population, direct internal and mucosal contact with NRL medical devices may be the route of sensitization as factors such as the number of procedures and use of NRL materials (catheters and tubes) were associated with increased risk of latex sensitization and allergy.

Pityriasis rubra pilaris (PRP) has always been an intriguing topic ever since its inception. It is a group of chronic disorders characterized by reddish orange plaques with pityriasiform scaling showing follicular keratoses, palmoplantar keratoderma, and sometimes, erythroderma. It occurs all over the world but with racial variations. Its incidence might vary and the age at onset, behavior, clinical appearance, and prognosis are considered to be very important for its classification. It may manifest either as Type I classical adult onset PRP, Type II atypical adult (onset) PRP, or Type VI PRP (HIV-associated PRP pityriasis rubra pilaris) in contrast to classical juvenile (Type III) and circumscribed juvenile (Type IV) encountered among children. Its diagnosis is largely clinical with microscopic pathology being a useful supplement, but it continues to be a therapeutic dilemma. We review the epidemiology of adult onset PRP here and take stock of the prevalent treatment options.

Background: In view of the relatively poor performance of skin smears WHO adopted a purely clinical operational classification, however the poor specificity of operational classification leads to overdiagnosis and unwarranted overtreatment while the poor sensitivity leads to underdiagnosis of multibacillary (MB) cases with inadequate treatment. Bacilli are more frequently and abundantly demonstrated in tissue sections. Aims and Methods: We compared WHO classification, slit-skin smears (SSS) and demonstration of bacilli in biopsies (bacterial index of granuloma or BIG) with regards to their efficacy in correctly identifying multibacillary cases. The tests were done on 141 patients and were evaluated for their ability to diagnose true MB leprosy using detailed statistical analysis. Results: A total of 76 patients were truly MB with either positive smears, BIG positivity or with a typical histology of BB, BL or LL. Amongst these 76 true-MB patients, WHO operational classification correctly identified multibacillary status in 56 (73.68%), and SSS in 43 (56.58%), while BIG correctly identified 65 (85.53%) true-MB cases. Conclusion: BIG was most sensitive and effective of the three methods especially in paucilesional patients. We suggest adding estimation of bacterial index of granuloma in the diagnostic workup of paucilesional patients.

Background: In the year 1998 WHO proposed that the clinical criteria of counting skin lesions alone should decide whether a patient receives Multibacillary (MB) or Paucibacillary (PB) MDT. There is a concern that a significant number of patients may be incorrectly treated under these guidelines. Aims: This study aims to determine whether the sensitivity and the specificity of the latest WHO criteria, can be enhanced by the addition of nerve examination in the place of slit skin smears. Methods: 150 patients of untreated leprosy reporting at a TLM Hospital in Delhi from January to December 2006 were registered for the study. After physical examination, the number of skin lesions and nerves involved were counted and slit skin smears performed. Two groups were created, those with > 5 skin lesions, and those with 5 or less skin lesions. The diagnostic efficacy of the current WHO classification was calculated with and without the addition of nerve examination. Results: The sensitivity and the specificity of the current WHO operational classification are 76.6%, and 73.7% respectively, using slit skin smear as a standard. When the number of nerves was added to the diagnosis, the sensitivity increased to 94.4%, for more than 5 lesions and to 90.9%, for five or less than five lesions. Conclusions: Nerve examination can significantly improve the sensitivity of the WHO criterion in determination of MB versus PB leprosy.

Quality of reporting and of methodology of studies on interventions for trophic ulcers in leprosy: A systematic review

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L Forsetlund, LM ReinarDOI:10.4103/0378-6323.42895 PMID:18797052

Background: In the process of conducting a systematic review on interventions for skin lesions due to neuritis in leprosy, we assessed several primary papers with respect to the quality of reporting and methods used in the studies. Awareness of what constitutes weak points in previously conducted studies may be used to improve the planning, conducting and reporting of future clinical trials. Aims: To assess the quality of reporting and of methodology in studies of interventions for skin lesions due to neuritis in leprosy. Methods: Items of importance for preventing selection bias, detection bias, attrition bias and performance bias were among items assessed. The items for assessing methodological quality were used as a basis for making the checklist to assess the quality of reporting. Results: Out of the 854 references that we inspected eight studies were included on the basis of the inclusion criteria. The interventions tested were dressings, topical agents and footwear and in all studies healing of ulcers was the main outcome measure. Reporting of both, methods and results suffered from underreporting and disorganization. The most under-reported items were concealment of allocation, blinding of patients and outcome assessors, intention to treat and validation of outcomes. Conclusion: There is an apparent need to improve the methodological quality as well as the quality of reporting of trials in leprosy ulcer treatment. The most important threat in existing studies is the threat of selection bias. For the reporting of future studies, journals could promote and encourage the use of the CONSORT statement checklist by expecting and requiring that authors adhere to it in their reporting.

Background:Mycobacterium leprae infection has recently been detected in wild armadillos in Brazil. Leprosy is still endemic in Brazil and although its transmission is mostly by person-to-person contact, many cases report no history of previously known leprosy contact. It has been suggested that other sources of M. leprae may contribute to the transmission of leprosy in some areas. Aim: Our objective was to investigate whether contact with armadillos is associated with leprosy. Methods: A case-control study was carried out in Brazil. Data was collected from 506 leprosy patients and 594 controls on exposure to armadillos and age, sex, place of birth and living conditions. Univariate analysis and unconditional logistic regression were conducted to investigate whether leprosy was associated with exposure to armadillos. Results: Direct armadillo exposure was reported by 68% of leprosy cases and by 48% of controls (P < 0.001) roughly doubling the risk of leprosy, with odds ratio (OR) 2.0, 95% confidence interval (CI) [1.36-2.99]. Conclusion: The results of this study suggest that direct exposure to armadillos is a risk factor for leprosy in Brazil.

Background : The calcium channel blocker, verapamil stimulates procollagenase synthesis in keloids and hypertrophic scars. Aim : To study the effect of verapamil in the treatment of hypertrophic scars and keloids and to evaluate the effect of verapamil on the rate of reduction of hypertrophic scars and keloids in comparison with triamcinolone. Methods : The study was a randomized, single blind, parallel group study in which 54 patients were allocated to to receive either verapamil or triamcinolone. Drugs were administered intralesionally in both groups. Improvement of the scar was measured using modified Vancouver scale and by using a centimeter scale serially till the scar flattened. Results : There was a reduction in vascularity, pliability, height and width of the scar with both the drugs after 3 weeks of treatment. These changes were present at one year of follow-up after stopping treatment. Scar pigmentation was not changed desirably by either drug. Length of the scars was also not altered significantly by either drug. The rate of reduction in vascularity, pliability, height and width of the scar with triamcinolone was faster than with verapamil. Adverse drug reactions were more with triamcinolone than with verapamil. Conclusion : Intralesional verapamil may be a suitable alternative to triamcinolone in the treatment of hypertrophic scars and keloids.

Background: Pemphigus is a common autoimmune blistering disorder in India. However, there are no population based surveys from India available to study the prevalence of this disease. Aims: To estimate the incidence of pemphigus in Thrissur district, Kerala, South India. Methods: Questionnaire based survey was conducted among the practicing dermatologists of Trichur district between 1 st January 2001 and 1 st January 2002 to determine the incidence of pemphigus in the district. Results: Ten cases of pemphigus vulgaris, one case of pemphigus erythematosus, and two cases of pemphigus foliacious were diagnosed during the study period in a population of 2.9 million in Thrissur district. The average age of pemphigus vulgaris patients was 58years in males [42 to 82 years] and 37 in females [25 to 57 years]. The average age of the two male pemphigus foliacious patients was 46 years [52 and 40 years] and the only pemphigus erythematosus patient was a 45 year-old female.Five cases of pemphigus vulgaris were investigated clinically histopathologically and by using direct immunofluorescence, while two were investigated clinically and histopathologically, two cases clinically, and one case clinically and with Tzanck smear. Two cases ofpemphigus foliacious were diagnosed with the aid of direct immunofluorescence and the only case of pemphigus erythematosus was diagnosed with the aid of direct immunofluorescence. Pemphigus vulgaris was common among females. The incidence of pemphigus in Thrissur district is 4.4 per million. Conclusions: This study indicates that the incidence of pemphigus in Thrissur district is high in comparison to the available studies from Germany, France, and the North African country Tunisia.

Background: Laboratory diagnosis of leprosy by slit skin smear and skin biopsy is simple but both techniques have their own limitations. Slit skin smear is negative in paucibacillary cases whereas skin biopsy is an invasive technique. Fine needle aspiration cytology (FNAC) from skin lesions in leprosy with subsequent staining with May-Grunwald-Giemsa (MGG) stain has been found useful. Aim: To evaluate the possible role of cytology in classifying leprosy patients. Methods: Seventy-five untreated cases of leprosy attending the outpatient department were evaluated. Smears were taken from their skin lesions and stained using the MGG technique. Skin biopsy was also done from the lesions, which was compared with cytology smears. Results: A correlation of clinical features with FNAC was noticed in 87.5% of TT, 92.1% of BT, 81% of BL, and 66% of LL cases. Correlation of clinical with histopathological diagnoses revealed 12.5% specificity in TT leprosy, 55.3% in BT, 52.4% in BL and 50% in LL, and 100% in neuritic and histoid leprosy cases. Both correlations were found to be statistically significant by paired t test analysis. Thus, it was possible to distinguish the tuberculoid types by the presence of epithelioid cells and the lepromatous types by the presence of lymphocytes and foamy macrophages. Conclusion: FNAC may be used to categorize the patients into paucibacillary and multibacillary types, but is not a very sensitive tool to classify the patients across the Ridley-Jopling spectrum.

Background: Several modalities of treatment have been tried in vitiligo with varied results; however, Indian data on comparative studies of two or more therapies are limited. Aims: We compared different phototherapy methods with an oral steroid as an adjunct to determine the method with the best tolerability and efficacy. Methods: Eighty-six patients with progressive vitiligo were randomly assigned to different study groups according to a continuous selection method over a period of one year. Group 1 was given OMP + PUVA, group 2 OMP + UVB (NB), group 3 OMP + UVB (BB) and group 4 was given OMP alone. Each patient was followed up for six months and then released from treatment. Clinical evaluation was made at the end of three and six months. Results: In group 1 (OMP + PUVA), marked improvement was seen in 18.51% while moderate improvement was seen in 66.66% of the patients. Marked improvement was seen in 37.03% in group 2 (OMP + NB-UVB) while 44.44% had moderate improvement. In group 3 (OMP + BB UVB), 8.33% showed marked improvement while moderate improvement was seen in 25% of the patients. Marked and moderate improvement was seen in 5 and 10% of group 4 (OMP) patients, respectively. Conclusions: Our study compared four treatment modalities in vitiligo patients, out of which oral minipulse of steroids (OMP) only had an adjunct value and was not very effective by itself. Narrow band UVB has a definite edge over broad band UVB and should be preferred when both options are available. NB-UVB and PUVA showed comparable efficacy.

Background: Histamine is the major mediator of allergic reactions. Newer H1 antihistaminics like levocetirizine, fexofenadine, and desloratadine are used in the treatment of seasonal and perennial allergic rhinitis and urticaria. The ability to block the cutaneous response to intradermal histamine is used to evaluate the potential of antihistamines. Aims: To compare the potency, onset, and duration of action of the commonly used antihistamines-levocetirizine, fexofenadine, and desloratadine Methods: Thirty volunteers were given three single doses of levocetirizine, fexofenadine and desloratadine at weekly intervals. A pretest was performed by using the intradermal histamine prick test. After administration of the drugs, the intradermal test was repeated at ˝, 1, 2, 3, 6 and 24 h, and the sizes of the wheal were measured. The mean values were taken and were compared by using Levene's t-test. Results: At 30 min, fexofenadine showed a statistically significant suppression of wheal size compared to levocetirizine and desloratadine. Two and three hours after administration, levocetirizine and fexofenadine showed statistically significant inhibition of wheal size while only levocetirizine had this effect after six hours when compared to desloratadine. Desloratadine showed greater inhibition of wheal size at the end of 24 h when compared to levocetirizine and fexofenadine but this was not statistically significant. Conclusions: Fexofenadine had the earliest onset of action while levocetirizine showed maximum inhibition of wheal response after three and six hours.

A diagnosed case of Castleman's disease, proven by biopsy from enlarged inguinal lymph nodes, presented with multiple, asymptomatic, erythematous papules and nodules prevalent since nine years over the trunk and extremities. The lesions had been gradually increasing in number and size. The patient had had plasmacytoma of the lower thoracic vertebra 12 years ago, for which he was adequately treated with chemotherapy and local radiotherapy. Dermatological examination revealed erythematous papules and nodules on the face, trunk, and extremities that were diagnostic of capillary hemangiomas. Histopathology of the erythematous, soft papule was suggestive of capillary hemangioma. Contrast-enhanced computerized tomography of the abdomen and pelvis showed multiple retroperitoneal nodes suggestive of Castleman's disease along with multiple osteolytic lesions in the pelvic girdle and vertebrae. The patient was treated with injection rituximab and is currently under follow-up. We report this case to highlight a rare association between Castleman's disease and POEMS syndrome.

A 53 year-old male diabetic presented with a month-old, painful ulcer with necrotic margins over the right thigh. Wound debridement was done twice and the ulcer showed recurrent growth of a white, cottony filamentous structure. Cutaneous mucormycosis was suspected and confirmed by histopathology and a culture isolate of Apophysomyces elegans . The patient was treated with liposomal amphotericin-B and itraconazole followed by partial thickness skin grafting, and then discharged after being prescribed posaconazole syrup for three weeks. Regular follow-up was done and during the last visit after six months following discharge, the ulcer was found to have healed well with no recurrence of the fungus.

We describe here a three year-old girl with classic clinical and histological features of juvenile hyaline fibromatosis. We found a history of similar skin findings in her eldest sister, in whom the disorder took a rapidly progressive and fatal course in the second year of life, suggesting either a very severe form of juvenile hyaline fibromatosis, or the possibility of infantile systemic hyalinosis. The similarities and differences between these two described types of hyalinoses have been reviewed in reference to the present report.

A two year-old male child presented with cutis marmorata congenita universalis, brittle hair, mild mental retardation, and finger spasms. Biochemical findings include increased levels of homocysteine in the blood-106.62 µmol/L (normal levels: 5.90-16µmol/L). Biochemical tests such as the silver nitroprusside and nitroprusside tests were positive suggesting homocystinuria. The patient was treated with oral pyridoxine therapy for three months. The child responded well to this therapy and the muscle spasms as well as skin manifestations such as cutis marmorata subsided. The treatment is being continued; the case is reported here because of its rarity. Homocysteinuria arising due to cystathionine beta-synthase (CBS) deficiency is an autosomal recessive disorder of methionine metabolism that produces increased levels of urinary homocysteine and methionine It manifests itself in vascular, central nervous system, cutaneous, and connective tissue disturbances and phenotypically resembles Marfan's syndrome. Skin manifestations include malar flush, thin hair, and cutis reticulata / marmorata.

Hodgkin's lymphoma in a patient of psoriasis treated with long-term, low-dose methotrexate therapy

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Uday Khopkar, Urmila BhorDOI:10.4103/0378-6323.42919 PMID:18797063

Methotrexate (MTX) is used in the treatment of a variety of diseases such as rheumatoid arthritis, dermatomyositis, juvenile rheumatoid arthritis and chronic plaque psoriasis. It has been well documented that there is a risk of development of lymphomas in these patients although none have been reported in patients of psoriasis treated with methotrexate. A 58-year-old male patient, a known case of psoriasis since 1994, had been receiving treatment with a low dose of MTX, 5 mg weekly for ten years intermittently (7-8 months/year). The cumulative dose of MTX taken was 1.5 gm. He developed high-grade fever with cervical lymphadenopathy that was nonresponsive to routine line of management. Lymph node biopsy revealed the presence of mixed cellularity type of Hodgkin's lymphoma. CT scan showed cervical, mediastinal and abdominal lymphadenopathy. The patient responded well to withdrawal of MTX and chemotherapy. This is the first case of lymphoma occurring in a patient of psoriasis treated with low-dose MTX.

Dr. U. B. Narayan Rao L.C.P.S (Bom) (born 23 rd November 1895, died 14 th June 1960) had a busy general practice in Bombay. He adopted dermatology and venereology as his specialty in the 1930's and started the Indian Journal of Venereal Diseases in 1935, the first of its kind in the subcontinent. This journal went on to become the official mouthpiece of the Indian Association of Dermatologists and Venereologists in 1955 and was then known as the Indian Journal of Dermatology and Venereology. Dr. Narayan Rao also played an important role as a founder member of the Bombay Association of Dermato-Venereologists as well as the Indian Association of Dermatologists and Venereologists. Activist, indefatigable worker dedicated to the cause, nationalist, and patriot, generous, dynamic and aggressive, with a flare for arguing; negotiating and convincing, and winning friends in the process, were some of the attributes that may be mentioned of this remarkable person who contributed so much to our specialty.

Personal Digital Assistants (PDAs) have become a part of everyday life. DermaMan is a freely available, Java-based, dermatology-specific calculator for handheld devices. It includes modules to compute PASI, MASI, SCORAD, and for calculations related to topical PUVA and Botox® administration.

Background: Cutaneous drug reactions are the most common adverse reactions attributed to drugs. Any skin disorder can be imitated, induced or aggravated by drugs. Aims: The present study was carried out to determine the age, sex incidence and clinical pattern of drug eruptions, to recognize offending drugs (self medication or prescribed), to evaluate mortality and morbidity associated with drugs, to educate the patients, and to avoid self-administration of drugs and re-administration of the offending drugs. Methods: The diagnosis of cutaneous drug reactions is mainly based on detailed history and correlation between drug intake and the onset of rash. Two hundred patients (112 males and 88 females) presenting with cutaneous drug reactions were studied. Results: Fixed drug eruption was seen in 61 patients; others being urticaria and angioedema, morbilliform rash in 37, pruritus in 25, Stevens Johnson (SJ) syndrome in six, purpura in six, exfoliative dermatitis in five, photosensitivity in five, Toxic Epidermal Necrolysis in two, acneiform eruption in three, and erythema multiforme in two patients. The most frequently affected age group was 41-50 years, followed by the 21-30 and 31-40 years age groups. The youngest patient was one year old and the oldest was 80 years old. The period of development of lesions after the intake of drug(s) varies from 01-45 days. Cotrimoxazole was the offending drug in 26 cases, followed by Ibuprofen in 20 cases. Conclusions: Fixed drug eruption was the most common drug eruption seen. Cotrimoxazole was the most common cause of drug eruptions.

Cyst formation in the parameatal area of the urethra is an uncommon entity. It was first reported in two male cases as recently as 1956 by Thompson and Lantin. Further reports have been rare. Herein, we report a case of a 21 year-old male having a spherical, cystic swelling 1 cm in size at the external urethral meatus. The diagnosis of parameatal urethral cyst was made and the cyst was excised. Histopathological examination revealed a monolocular cyst lined with transitional cells. The postoperative period was uneventful.